Between Crisis and Convention: How Should We Address Contingency?

The Covid-19 pandemic has brought about renewed conversation about equality and equity in the distribution of medical resources. Much of the recent conversation has focused on creating and implementing policies in times of crisis when resources are exhausted. Depending on how the pandemic develops, some communities may implement crisis measures, but many health care facilities are currently experiencing shortages of staff and materials even if the facilities have not implemented crisis standards. There is a need for shared conversation about equality and equity in these times of contingency between conventional and crisis medicine. To respond well to these challenges, I recommend that institutions rely on policy, professional education, and ethics consultation. As is the case with crisis policies, creating contingency policies requires that health care professionals decide on how, specifically, to achieve equity. A policy is only as effective as its implementation; therefore, institutions should invest in context-specific education on contingency policies. Finally, ethics consultation should be available for questions that contingency policies cannot address.

Crisis Standards of Care Implementation at the State Level in the United States.

INTRODUCTION: In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed. PROBLEM: Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed. METHODS: An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning. RESULTS: Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17). CONCLUSION: Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

General practitioners in the field: A qualitative study of general practitioners' experiences in disaster healthcare.

METHOD: A qualitative study using semi-structured interviews was conducted with a purposive sample of GPs who had experienced disasters in Australia or New Zealand (NZ) between 2009 and 2016. Transcripts underwent thematic analysis. RESULTS: Thirty-eight GPs reported diverse and effective contributions to disaster-response efforts. Four main themes emerged: GPs responded spontaneously to contribute; GPs adapted their usual expertise to provide disaster healthcare; personal and professional challenges experienced were consistent across different types of disaster; and unlike Australian GPs, NZ GPs felt better integrated and valued in the broader disaster-response system. DISCUSSION: The results document GPs' roles and experiences in disaster healthcare and highlight how GPs contribute to meeting crucial healthcare needs in communities during and following disasters. Better defining, integrating and supporting GP roles in disaster systems is likely to improve disaster healthcare.

Mass Casualties and Case Management.

The mass casualty statistics in the United States is numbing. Case managers must be prepared for potential disasters. This Editorial speaks to a case manager's personal experience and calls for others who have been through an experience with mass casualties, so all may better prepare: preparation is the antidote to panic.

Rehabilitation in Disaster Relief.

Rehabilitation plays a crucial role in natural disasters owing to the significant upsurge of survivors with complex and long-term disabling injuries. Rehabilitation professionals can minimize mortality, decrease disability, and improve clinical outcomes and participation. In disaster-prone countries, skilled rehabilitation workforce and services are either limited and/or comprehensive rehabilitation-inclusive disaster management plans are yet to be developed. The World Health Organization Emergency Medical Team initiative and guidelines provide structure and standardization to prepare, plan, and provide effective and coordinated care during disasters. Many challenges remain for implementation of these standards in disaster settings and integrating rehabilitation personnel.

Response Functions in Disasters: Iran Flash Flood 2016.

OBJECTIVE: Heavy rain and flash flooding left behind a trail of disaster in the western and south-western provinces of Iran in April 2016. The purpose of this study is to highlight the response functions that should be undertaken when such disasters strike. METHODS: Secondary data, such as documents, organizational reports, and forms completed during response to the flood visits, were the methods of data collection in this study. Then, collected data were analyzed according to the response functions to disasters. RESULTS: The study found that a strong disaster response function was the early warning system, by the Iran Meteorological Organization, announced 1 week before the flood. Weaker functions were the lack of coordination among response organizations and the lack of a safety officer in the Incident Command System structure during the flash flood. CONCLUSIONS: The list of the disaster response functions identified by this study should aid the decision makers and first responders in facing natural or man-made disasters and enable them to better prepare for response functions in the future disasters.

Characterizing the Current State of Training Courses Available to US Disaster Professionals.

OBJECTIVE: The objective of this study is to characterize US-based disaster training courses available to disaster response and disaster health professionals. Its purpose is to better inform policies and decision-making regarding workforce and professional development to improve performance. METHODS: Courses were identified from 4 inventories of courses: (1) National Library of Medicine Disaster Lit database; (2) TRAIN National Learning Network; (3) Federal Emergency Management Agency (FEMA) National Preparedness Course Catalog; and (4) Preparedness and Emergency Response Learning Centers. An online search used 30 disaster-related key words. Data included the course title, description, target audience, and delivery modality. Levels of learning, target capability, and function were categorized by 3 expert reviewers. Descriptive statistics were used. RESULTS: There were 3662 trainings: 2380 (65%) for professionals (53% for public health); 83% of the courses were distance learning, with 16% via classroom. Half of all trainings focused on 3 of 37 disaster capabilities and 38% of them were related to chemical, biological, radiological, nuclear, and explosives (CBRNE). The educational approach was knowledge-based for all courses and 99.6% imparted only lower levels of learning. CONCLUSION: Despite thousands of courses available, there remain significant gaps in target audience, subject matter content, educational approaches, and delivery modalities, particularly for health and public health professionals.

The next generation core competencies for emergency management.

The Next Generation Core Competencies (NGCC) guide the professional development of future emergency managers. Once familiar roles are evolving as the world grows more interdependent; at the same time, disaster risk factors are intensified by the changing interactions between the social, built, and physical environments. The updated edition of emergency management core competencies is particularly important for refining the trajectory of the emergency management discipline and developing capacities requisite to reducing disaster risk and building resilient communities in the midst of a turbulent, complex, and uncertain future. The NGCC project was a multiphase study conducted by a FEMA-sponsored focus group. Oriented toward future needs, the competencies have been built on the current emergency management competencies, a review of related competencies and global risk trends, a multiphase Delphi study, and wider emergency management community listening sessions. Behavioral anchors and key actions for measurement accompany the new core competencies. The overarching goal of the work is to establish the next generation emergency management core competencies, which are likely to underpin the emergency management workforce of 2030 and beyond. The 13 core competencies fall into three nested categories that are interrelated, but have attributes that build the individual, the practitioner, or relationships.

Research Methods and Ethics in Health Emergency and Disaster Risk Management: The Result of the Kobe Expert Meeting.

In October 2018, at Asia Pacific Conference for Disaster Medicine (APCDM), an expert meeting to identify key research needs was organized by the World Health Organization (WHO) Centre for Health Development (WHO Kobe Centre (WKC)), convening the leading experts from Asia Pacific region, WHO, WHO Thematic Platform for Health Emergency and Disaster Risk Management (Health-EDRM) Research Network (TPRN), World Association for Disaster and Emergency Medicine (WADEM), in collaboration with Asia Pacific Conference for Disaster Medicine (APCDM) and Japan International Cooperation Agency (JICA). International experts, who were pre-informed about the meeting, contributed experience-based priority issues in Health-EDRM research, ethics, and scientific publication. Two moderators, experienced in multi-disciplinary research interacted with discussants to transcribe practical issues into related methodological and ethical issues. Each issue was addressed in order to progress research and scientific evidence in Health-EDRM. Further analysis of interactive dialogues revealed priorities for action, proposed mechanism to address these and identified recommendations. Thematic discussion uncovered five priority areas: (1) the need to harmonize Health-EDRM research with universal terms and, definitions via a glossary; (2) mechanisms to facilitate and speed up ethical review process; (3) increased community participation and stakeholder involvement in generating research ideas and in assessing impact evaluation; (4) development of reference materials such as possible consensus statements; and (5) the urgent need for a research methods resource textbook for Health-EDRM addressing these issues.

Disaster Management in a Nephrology Service: Lessons Learned from Hurricane Maria.

BACKGROUND: Puerto Rico suffered a major humanitarian -crisis after Hurricane Maria. We describe our experience with patients with renal disease in an academic medical center. SUMMARY: A comprehensive emergency response plan should be developed, shared and discussed with the team and the patients prior to the hurricane. The needs of the staff should not be ignored to ensure their ability to participate as responders. Physical damage to facilities, lack of basic services, shortage of disposable products, and the inability to get to treatment centers are the most common threats. Preemptive dialysis can avoid serious complications. A contingency plan to move patients to another center should be prearranged in case the unit is rendered nonfunctional after the storm. Patients must receive preventive education about fluid and dietary restrictions and the possible use of potassium binding drugs if they cannot reach a dialysis unit. A list of alternative drugs that could be used if patients are not able to fill their medications is required. The Internet and social media proved to be an invaluable communication tool. A registry of patients with updated contact information, as well as contact information for relatives and a physical address where an emergency rescue team can be dispatched is essential. Water safety should be reinforced. Key Message: Our experience showed us that preparing for the worst is not enough. Advanced planning of a streamlined response is the best tactic to decrease harm.

Knowledge Maps of Disaster Medicine in China Based on Co-Word Analysis.

OBJECTIVE: We analyzed research themes in the field of disaster medicine in China to provide references for researchers to understand the research status and developing trends of this field. METHODS: Published journal articles were retrieved. A social network analysis was conducted to visualize the relations of high-frequency key words. A cluster analysis was used to classify key words. A strategic diagram analysis was conducted to visualize clusters across the entire research field. RESULTS: We retrieved 3,079 articles, from which 1,749 articles and 8,284 key words were identified after screening. High-frequency key words were classified into 6 clusters. "Medical rescue" had the highest degree and betweenness centralities. Cluster 4 was located in Quadrant I of the strategic diagrams. CONCLUSIONS: "Medical rescue" is the core key word, and it serves a pivotal "bridge" function. "Emergencies" and similar terms are key words with special statuses. "Natural disaster medical rescue" and "fundamental theories of disaster medicine" constitute the primary and secondary core themes, respectively. "On-site emergency treatment techniques" is a marginalized theme. The other themes are emerging themes that offer considerable scope for future development. Generally, the scope and depth of investigations in this field should be improved. (Disaster Med Public Health Preparedness. 2019;13:405-409).

Precision Health in Disaster Medicine and Global Public Health.

Current debates about precision medicine take different perspectives on its relevance and value in global health. The term has not yet been applied to disaster medicine or humanitarian health, but it may hold significant value. An interpretation of the term for global public health and disaster medicine is presented here for application to vulnerable populations. Embracing the term may drive more efficient use and targeting of limited resources while encouraging innovation and adopting the new approaches advocated in current humanitarian discourse. PatelRB. Precision health in disaster medicine and global public health. Prehosp Disaster Med. 2018;33(6):565-566.

Epidemiological Effectiveness and Cost of a Fungal Meningitis Outbreak Response in New River Valley, Virginia: Local Health Department and Clinical Perspectives.

OBJECTIVE: We evaluated the effectiveness and cost of a fungal meningitis outbreak response in the New River Valley of Virginia during 2012-2013 from the perspective of the local public health department and clinical facilities. The fungal meningitis outbreak affected 23 states in the United States with 751 cases and 64 deaths in 20 states; there were 56 cases and 5 deaths in Virginia. METHODS: We conducted a partial economic evaluation of the fungal meningitis outbreak response in New River Valley. We collected costs associated with the local health department and clinical facilities in the outbreak response and estimated the epidemiological effectiveness by using disability-adjusted life years (DALYs) averted. RESULTS: We estimated the epidemiological effectiveness of this outbreak response to be 153 DALYs averted among the patients, and the costs incurred by the local health department and clinical facilities to be $30,413 and $39,580, respectively. CONCLUSIONS: We estimated the incremental cost-effectiveness ratio of $198 per DALY averted and $258 per DALY averted from the local health department and clinical perspectives, respectively, thereby assisting in impact evaluation of the outbreak response by the local health department and clinical facilities. (Disaster Med Public Health Preparedness. 2018;12:38-46).

Why a disaster is not just normal business ramped up: Disaster response among ED nurses.

BACKGROUND: The emergency department (ED) is a familiar place for the emergency nurse who spends their working days inside it. A disaster threatens that familiarity and creates changes that make working in the ED during a disaster response different from the everyday experience of working in the ED. METHODS: This research reports on an aspect of the findings from a larger study about the experience of working as a nurse in the ED during a disaster response. Thirteen nurses from 8 different countries were interviewed about their experience. RESULTS: The findings from this research demonstrate that a disaster event leads to a chain reaction of changes in process, space and practice. Nurses' respond to the news of a disaster event with shock and disbelief. The ED may change as a result of the event requiring nurses to work in an altered environment or a completely different setting. These changes provoke nurses to alter their behaviour and practice and reflect on the experience after the response. CONCLUSIONS: Emergency nurses have a high likelihood of participating in disaster response and as such should be adequately prepared. This highlights how disaster response is different and leads to recommendations to enhance training for emergency nurses which will better prepare them Disasterresponse is not normal business ramped up. There are a number of challenges and changes that should be considered when preparing emergency nurses for the realities of disaster response.

Medical and policy considerations for nuclear and radiation accidents, incidents and terrorism.

PURPOSE OF REVIEW: The purpose of this review is to address the increasing medical and public concern regarding the health consequences of radiation exposure, a concern shaped not only by fear of another Chernobyl or Fukushima nuclear power facility accident but also by the intentional use of a nuclear weapon, a radiological dispersion device, a radiological exposure device, or an improved nuclear device by rogue states such as North Korea and terrorist organizations such as Al Qaeda and ISIS. RECENT FINDINGS: The United States has the medical capacity to respond to a limited nuclear or radiation accident or incident but an effective medical response to a catastrophic nuclear event is impossible. Dealing effectively with nuclear and radiation accidents or incidents requires diverse strategies, including policy decisions, public education, and medical preparedness. SUMMARY: I review medical consequences of exposures to ionizing radiations, likely concomitant injuries and potential medical intervention. These data should help haematologists and other healthcare professionals understand the principles of medical consequences of nuclear terrorism. However, the best strategy is prevention.

17 A. Atentado terrorista en Barcelona: primeras impresiones / August 17: First reflections after the terrorist attack in Barcelona

No disponible